MEDICAL RECORDS                                                                                                                                  35-02-003

 

RETENTION, MAINTENANCE AND RETRIEVAL
 OF MEDICAL RECORDS

 

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey Veterans Memorial Homes (VMH) establishes a medical records retention, maintenance and retrieval system, ensuring medical records are properly organized, safe from loss, destruction or unauthorized use, and readily accessible and easily retrievable as needed for reference. 

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a medical records retention, maintenance and retrieval system ensuring the medical records of all deceased or discharged residents are properly organized, kept safe from loss or destruction, are readily accessible and easily retrievable, as needed for reference for a period of ten (10) years, in accordance with N.J.A.C. 8:39-35.2(k).

PROCEDURE.

  1. Upon the seventh (7th) day following the death or discharge of a resident residing at one of the New Jersey Veterans Memorial Homes, the medical record shall be forwarded from the Nursing Unit to the Medical Records Department for assembly and examination.  Following review, the record is stored by year and in alphabetical order, or by resident identification number within that particular year.

  2. Medical records for the current year, plus the two years previous to the date of demise or discharge, will be kept in the facility in the Medical Records file room and stored as cited above in paragraph A.

  3. Medical records for the eight (8) previous years will be stored in an archive file room or an off-site location with a contract vendor.  The Medical Records Supervisor manages all storage, tracking, and retrieval of the Medical Records while at the off-site location.  The turn-around-time for delivery of any requested medical record from the off-site location shall not exceed a 48-hour period.

  4. All medical records shall be reassembled into one complete record at the end of the required ten (10) year retention period.  The discharge summary sheets are to be removed and retained in accordance with N.J.A.C. 8:39-35.2(k), the balance of the record shall be shredded, and a note entered onto the Facility Destruction Log, as required by HIPAA Regulations.

  5. A summary sheet of each medical record shall be retained for a period of twenty (20) years, and X-ray films or reproductions thereof shall be retained for a period of five (5) years.

Revised:   July 2007
Revised:   April 2010

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